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Institutional Equity and Compliance

Disability Disclosure Form


Full Name  

Division/Office/Unit

Position

Disability Status:

A disabled person is anyone who: (1) has a physical or mental impairment which substantially limits one or more of the major life activities; (2) has a record of such impairment; (3) is regarded as having such an impairment.

Please check beside any disability which applies to your situation.

Upper & Lower Extremities, e.g., amputation, finger disability
Hearing Impaired
Speech Impaired
Cardiovascular
Respiratory, except Asthma
Widespread Paralysis or Muscular Dysfunction, e.g., multiple sclerosis, paraplegia, cerebral palsy, epilepsy, Parkinson's disease.
Neuropsychiatric, e.g. personality disorder, head injuries, alcoholism and drug addiction (Rehabilitated Drug User only)
Retardation, e.g., mentally impaired
Trunk, Spine & Abdominal defects e.g., hernia, disk, spinal fusion
Vision impaired
Skin, Cosmetic & Allergy conditions, e.g., facial disfigurement, asthma, allergic dermatitis, skin disease
Generalized or Systemic Diseases, e.g., diabetes, arthritis, leukemia, cancer, diseases of the blood
Gastrointestinal, e.g., ulcer, colitis, colostomy paraplegia, cerebral palsy, epilepsy, Parkinson's disease
Genitourinary
Other disabilities, please explain below.
 

2011 Middle Tennessee State University, a Tennessee Board of Regents institution 1301 East Main Street, Murfreesboro, TN 37132-0001 USA +1.615.898.2300

Middle Tennessee State University, in its educational programs and activities involving students and employees, does not discriminate on the basis of race, color, national origin, sex, religion, or age. Furthermore, the university does not discriminate against veterans or individuals with disabilities.

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